HospitalInspections.org

Based on review of facility policy, patient records, and confirmed in interview, the facility failed to ensure four of ten patients (Patient #K, L, M, P) were provided with an environment which promoted personal privacy and dignity. Patient #K, L, M, P were assigned alternative sleeping arrangements for greater than 24 hours.

Findings included:

Review of facility policy Admission/Intake (Policy AIM 105, revised 07/23) under Room Assignments it stated "Patient unit and room assignments and levels of monitoring shall be made on the basis of: a) the needs of the patient; b) the needs of other patients on a unit; c) the attending physician's request or approval; d) space available. Patients may be admitted to a unit and transferred to another unit based upon the patient's needs and other patient's needs. Patients may consent to alternative sleeping arrangements and transferred to another available bed by the next day."

In an interview with Staff # 2 on 09/04/2024 at 11:00 AM in the conference room, she described the alternative sleeping arrangements as temporary and less than 24 hours. The facility would provide the patient with a mattress on the floor in either the seclusion room and/or day room at night to sleep. During the day, the mattress will be stored away. The patient may or may not have access to a private room during the day depending on the room availability. The patients still participate in the programming.

Random review of patient records from August 2024 revealed the following four of ten patients who were assigned an alternative sleeping arrangements for longer than 24 hours.

Patient #K
Review of observation rounds revealed Patient # K slept in the TV room on 08/16/2024, 08/17/2024, 08/18/2024, 08/19/2024. Patient #K was assigned Room 808B on 08/20/2024.

Patient # L
Patient #L was originally assigned Room 801A at admission on 08/13/2024. Review of observation rounds revealed Patient # L slept in the Quiet Room 08/16/2024, 8/17/2024, 8/18/2024. She discharged on 08/19/2024.

Patient # M
Review of observation rounds revealed Patient # M slept in the Quiet Room 08/16/2024, 8/17/2024, 8/18/2024, 08/19/2024, 08/20/2024 . Patient # M was assigned Room 703B on 08/21/2024.

Patient # P
Review of observation rounds revealed Patient # P slept in the TV Room 8/17/2024, 8/18/2024, and 08/19/2024. Patient # P was assigned Room 702B on 08/20/2024.

No doctors orders were available for review to indicate the alternative sleep arrangements were for patient safety.

In an interview with Staff #1 via Teams on 09/10/2024 confirmed the above findings. She stated that the above patients consented to the alternative sleep arrangements but it was not clear that it could be greater than 24 hours.

Based on review of facility records, patient charts, and confirmed in interview, the facility failed to provide care in a safe setting for one of ten patients reviewed. The facility failed to ensure Patient # G who had a history of peer and staff violence did not have an opportunity to injure Patient # C.

Findings included:

Patient #G chart

In review of Patient #G chart, she was admitted on 07/11/2024 for suicidal ideation with plans to overdose.

Random review of nursing, progress, and therapy notes from July 2024 included the following five incidents of aggressive behaviors with no change in her level of observations.

Nursing Notes on 07/11/2024
"Patient [G] got into a brawl fight with another patient on the unit refusing multiple redirections and became uncontrollable making the unit chaotic and triggering other patient danger to self and other. Staff initiated a code green."

Nursing Notes on 07/13/2024
"Patient [G] is visible in the unit. She is very disruptive. She was trying to attack [patients] most of the time. Patient received haldol/benadryl to help with her aggressive behavior."

Nursing Notes on 07/17/2024
"[Patient G] became agitated and verbally and physically aggressive to peers and staff. Required emergent IM med to assist her..."

Nursing Notes on 07/19/2024
"[Patient G] was trying to fight another [patient] without any provocation. She was redirected multiple times but refused redirections. She became uncontrollable climbing tables, threatening and swearing other peers, throwing things on the floor, becoming disruptive on the unit."

Physician progress note 07/20/2024
"Threatening to cut her arm if she does not get her green band back today. [Patient G] lost her green band yesterday due to increased aggressive behaviors. Per report patient became very disruptive yesterday climbing tables and threatening peers."

Nursing Notes on 07/21/2024
"At 1423 report received from recreational therapist that [Patient G] ran towards therapist during recreational therapy. Therapist paused for a second kicked her shoes off and then [Patient G] attacked the therapist. [Patient G] hit therapist three times and then started pulling her hair and would not let go. The recreational therapist and two techs had to pull [Patient G] off the therapist.."

Physician progress note 07/22/2024
"remains hyperactive and impulsive. poor boundaries, reports mood swings. stated 'I beat up the therapist because she was rude' less irritable but still anxious and unpredictable."

Therapy Notes on 07/22/2024
"[Patient G] on 07/19/2024 was trying to fight another [patient] without any provocation, [patient] was climbing table, threatening and scaring other [patients]. On 07/21/2024 [Patient G] ran towards therapist and attacked her. [Patient G] hit therapist in the head and pulled her hair. On 07/21/2024 [Patient G] became defiant, aggressive towards unit, and disrupt the unit."

Nursing Notes on 07/23/2024
"at 1823 [Patient G] attacked peer unprovoked. She came up behind peer and threw her on the ground and would not let go of her. Staff intervened. [Patient G] escorted to seclusion. No injury to this patient."

Patient #C

In review of Patient #C chart, she was admitted on 07/22/2024 for DMDD (disruptive mood dysregulation disorder).

In review of the nursing and ER (emergency room) notes stated the following:

nursing notes on 07/23/2024 at 1100
"[Patient C] awake, alert, oriented. Denies suicidal/homicidal ideation and hallucinations. Reports depression 8/10 and anxiety 7/10. Reports 'staying to myself' to avoid drama with others. No thoughts of hurting herself...."

Nursing notes on 07/23/2024 at 1920
"at 1823, [Patient C] was attacked by a peer. The peer came up from behind threw patient down causing her to hit head and [left] hand on the floor...order received to send to [ER located on 6621 Fannin] for evaluation.

Review of ER records on 07/23/2024

"Physical Assault (coming from [facility]/ she was slapped on yesterday, her face slammed to tile floor, and hair pulled by another patient there yesterday. Today while trying to report and file charges the same patient assaulted her again and while the staff was trying to get the other patient off of her the patient fell to the floor with right being caught under her body. [Patient C] is complaining of pain in her right arm and hand. PMS intact/2nd digit swollen, and 3rd, 4th digit is painful to move."

"Patient is a 14 year old female with PMH bipolar type 2, anxiety, depression who presents from [facility] for
physical assault. Patient with a negative Ct head and negative XRs of the RUE. Little concern for intracranial bleed or
skull fracture, patient likely has a concussion given head trauma and symptoms of nausea, light-headedness and
headache. Patient likely has contusions to right wrist, hand and digits given pain, swelling, bruising and negative Xrs.
Medical clearance labs unremarkable, mildly elevated WBC likely reactive given no infectious symptoms. Given that
patient has been assaulted multiple times at [facility] and does not feel safe, social work consulted and plan to
move patient to a different inpatient psychiatric facility. Patient is medically cleared."

An interview with Staff #1 via teams on 09/10/2024 at 4:15 PM confirmed the above findings. She stated that Patient G was placed on unit restrictions after her incident on 07/21/2024. However, unit restrictions did not prevent her from injuring another patient in the unit.